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SonoCase: Pediatric lower abdominal bulge? What the…?

You know, working in the pediatric ER is always a joy since most children are going to do well (and most parents are worry warts – but who am I kidding, I would be too!). But sometimes I get a case that surprises me – and this is one of them. Of course, in hindsight, it makes sense, but still interesting given the way the kid presented: 4 year old boy, with a history of “retractable bulges a few years ago” comes to the ER after his mom noticed that he woke up that morning (4 hours prior to arrival) walking funny. She took down his very cute Star Wars pajama pants and saw this:

It was red and painful so she thought, “oh no, his bulge is back.” She took him to the ER where I saw and took the picture above with their consent. He was in no distress at all, smiling when I started joking about menacing Sith lords, and pulled down those Star Wars pants on his own where I saw the bulge above. I pressed around that area first, and those areas were not tender. I then examined his scrotum where I saw no signs of inflammation/swelling and could not palpate either testicle, neither of which bothered him at all. I placed 2 fingers into the inguinal canal, felt the spermatic cords, and that hurt him on the left but not as much as when I palpated directly on the bulge, which was above the inguinal ligament: it was red, warm, and firm/nonfluctuant. Of course, I immediately grabbed the linear probe and slowly slid over the bulge: was it bowel? was it an abscess? was it a lymph node? could it be the testicle? This is what I saw:

Starting from the top, there is definite cobblestone appearance to suggest cellulitic skin (normal skin will appear more isoechoic (same shades of gray). Then deep to that is a circular noncompressible structure that has a darker outer layer and an echogenic (gray) center. It was without peristalsis and had no flow over it when the color doppler box was placed over it. I placed the probe over each scrotal sac and could not visualize either testicle. It was no abscess or lymph node, and definitely not bowel – – Turns out, it was a retracted testicle with significant surrounding edema (the darker area) that went through the inguinal canal and torsed, seen on exam as a LLQ red firm bulge!

The key to diagnosing testicular torsion is first: visualization of the testicle with the linear probe in transverse, coronal, and longitudinal views. Slowly sliding through the entirety of the testicle you will notice its normal isoechoic appearance without surrounding fluid or edema. (see video below of a normal adult testicle). Placing the Color doppler box over the testicle, you should see vascular flow as seen in the video below to rule out torsion. And, its like one of my mentors said while moving his arms around like he was a rap star repeating over and over again , “If no Flow, you gotta call Uro. Time is testicle, helps make miracles. If no Flow, you gotta call Uro…”